Archived: Gorton Parks Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of the legal regulations relating to good governance.

The provider was previously in breach of the legal regulation in relation to safe care and treatment, person-centred care, safe care and treatment and staffing. At this assessment, we found the provider remained in breach of the regulation.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and needs of people and their communities.

The provider had failed to improve the homes environment since the last assessment. They had failed to promote a culture of safety and promote the behaviours of staff to ensure people received person-centred and safe care.

Staff told us, they reported concerns to the maintenance team, but it was evident, action to ensure fixtures and fittings of the home were safe and functioning was not a priority to the provider.

Our observations of poor care included failing to communicate with people, providing meals with poor nutritional value and a failure to support people to be hydrated. Staff were visibly busy, and the provider had not recognised the impact this had on staff and the people they supported.

There was a failure to improve outcomes for people who were regularly refusing personal care interventions, and no further strategies had been implemented to ensure people received the correct support to manage their skin integrity and oral hygiene. Staff failed to identify where people were not presenting as their best self which included having long and unclean fingernails, were visibly unkempt and for some people they were living in an unclean environment.

Leaders were not visible at every level. Leaders were not knowledgeable about issues and priorities for the quality of the service. A manager had been in post at the home for several months and had applied to register with the Care Quality Commission.The manager was supported by a deputy manager, a clinical lead who was new to the home since the last inspection and a unit manager. There was a wider team of divisional directors responsible for monitoring the quality of the home. We found leaders were not visible at every level and there was a failure to sustain high quality leadership and to lead effectively in identifying and addressing concerns impacting on the safety and quality of care received by people. The manager had only received video calls from quality monitoring leaders, and no one was actively checking the managers work. Email requests for improvements to be made across the home were not always followed up by the provider which impacted on the condition of the home. Staffing and food budgets had been reduced which impacted on the quality of people’s care. A relative told us, they were wary of raising concerns about the care in case it impacted upon the placement of their relation at the home.

Staff told us, they could speak to the management about concerns, but they were not always sure the senior leadership team were listening to the concerns.

We received mixed feedback from relatives when they raised concerns. One relative told us, “The manager didn't really speak to me much about the issue. I felt like there were a few things covered up and I don't think they wanted CQC involved.”

A whistleblowing policy was in place and staff were aware of the policy.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance processes were ineffective as they were not capturing where improvements needed to be made. Clinical audits were often completed by the unit manager who did not have a good understanding of reviewing clinical practice. We reviewed the clinical audits for Abbey Hey House and found it was recorded thickening protocols had been fully completed evidencing safe administration and hydration needs being met. However, the audit had not identified people were receiving incorrect levels of fluid per ratio thickener which place them at risk of choking or aspirating.

Staff had been provided with one-to-one supervisions to support them to safely administer thickener, but we observed staff not following the instructions of adding the thickener to the cup before the fluid and then waiting for the drink to reach its consistency before serving. This had also not been highlighted as part of the audit.

The audit had recorded positional changes were planned to reduce the risk of pressure injuries but did not highlight where people were being repositioned in the same position which contributed to pressure damage to the skin.

Infection control audits across the home recorded the home’s overall rating as good which was not in line with our findings. We found staff were not wearing face masks during an infectious outbreak. We found people were not offered hand hygiene before meals and equipment, furnishings were not in a good state of repair and visibly clean and free from dust.

Medicines audits were not highlighting our findings in relation to the safe management of medicines.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider told us, they had worked with partner agencies to improve the home, and they had been informed the home was compliant from an infection control and quality monitoring perspective. The provider told us improvement work to the homes including fixtures and fittings had been signed off as complete, but we found no evidence, the provider had visited the homes separate houses to review the work for themselves to and check improvements were satisfactory.

We reviewed reports and action plans from partners which confirmed, there was further work to be done, especially in relation to infection control and medicines management.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Staff and leaders did not have a good understanding of how to make improvements happen. The provider had not considered how reducing staffing had impacted on the care and treatment provided to people and had failed to identify people were not being supported in a safe and person-centred way.

At the last assessment, we highlighted staff were not recording information in the electronic care plan in real time and we found the same concerns at this assessment when we observed staff inputting where people had received care and support which was not in line with our observations.

We fed back to the manager on our first day on site, where people had swallowing difficulties should avoid eating ice cream as it increases the risk of aspiration and we found on the second visit, 4 days later, people with a reduced swallowing ability had been continued to be provided with ice cream.

We found the provider had failed to adhere to the warning notice served following the last assessment. Improvements had not been made to the homes internal and external environment and risks to people at risk of pressure injuries and swallowing risks had not been effectively met. The management of medicines continued to be poor, and the provider had failed to improve the recording of contemporaneous records for people using the service.